Accuracy Of Dobutamine Stress Echocardiography Research Articles

Influence of gender on the diagnostic and prognostic significance of the dobutamine stress echocardiography for ischemia

Background/Aim. Cardiovascular diseases are the most common cause of mortality and morbidity worldwide, with the highest incidence in low-middle-income countries. Dobutamine stress echocardiography (DSE) plays a significant role in diagnosing coronary artery disease. The aim of the study was to examine the influence of gender on the accuracy of DSE and on the prognostic significance of the left ventricular wall motion score index (WMSI) as a parameter of DSE for adverse cardiovascular events (ACEs). Methods. The prospective, observational study conducted at the Clinic for Cardiovascular Diseases of the University Clinical Center of the Republic of Srpska, Bosnia and Herzegovina, included 143 patients who, due to suspicion of coronary disease, underwent a DSE from January 1, 2021, until February 1, 2022. ACEs that we observed one year after DSE were: unstable angina, acute myocardial infarction, percutaneous coronary intervention, in-stent restenosis, aortocoronary bypass, heart failure, and death. Results. A positive DSE was more common in men (45%) compared to women (25%), which was statistically significant (p < 0.05). The sensitivity of the test in men was 96.0%, and the specificity was 93.9%. In women, the sensitivity was 86.7%, and specificity was also 86.7%. ACEs were more frequent in men (43%) than in women (19%), which was statistically significant (p < 0.01). In men, WMSI had a sensitivity of 96.0% and a specificity of 82.4%. In women, WMSI had a sensitivity of 93.3% and a specificity of 90.6% in predicting ACEs. Conclusion. Our results confirmed the influence of gender on the accuracy of DSE in diagnosing coronary artery disease. WMSI as a parameter of DSE was identified as a significant prognostic factor for ACEs in both sexes, with the sensitivity being higher in men and specificity in women.

Left Ventricular Myocardial and Cavity Velocity Disturbances Are Powerful Predictors of Significant Coronary Artery Stenosis.

Background and Aim: Dobutamine stress echocardiography (DSE) is a well-established noninvasive investigation for significant coronary artery disease (CAD). The aim of this study was to evaluate the accuracy of cardiac Doppler parameters in predicting CAD. Methods: We prospectively studied 103 consecutive patients with suspected CAD based on typical symptoms; 59 proved to have CAD, and 44 patients proved to have no-CAD (n = 44). All patients underwent a complete stress Doppler echocardiographic examination. Total isovolumic time (T-IVT) as a marker of cavity dyssynchrony and wall motion score index (WMSI) were also calculated. Results: At peak dobutamine stress, the compromised LV longitudinal excursion (MAPSE), systolic septal and lateral velocities (s’), and diastolic indices were more pronounced in the CAD patients compared with those without CAD, but LV dimension did not differ between groups (p > 0.05). The WMSI was higher and t-IVT more prolonged in patients with CAD (p < 0.01 for both). Similarly, the changes were more pronounced in patients with significant CAD compared with insignificant CAD. On multivariate model, Δ mean s’, OR 2.016 (1.610 to 3.190; p < 0.001), Δ E velocity OR 2.502 (1.179 to 1.108; p < 0.001), Δ t-IVT 2.206 (1.180 to 2.780; p < 0.001) and Δ WMSI OR 1.911 (1.401 to 3.001; p = 0.001) were the most powerful independent predictors of the presence of CAD, particularly when significant (>75%). Δ mean s’ < 5.0 was 85% sensitive, 89% specific with AUC 0.92. Respective values for Δ E velocity <6.0 cm/s were 82%, 90% and 0.91; for Δ t-IVT > 4.5, 78%, 77% and 0.81 and for Δ FT ≥ 150 ms, 76%, 78% and 0.84 in predicating significant CAD. WMSI ≥ 0.7 was 75% sensitive, 77% specific with AUC of 0.81 in predicting significant CAD. The accuracy of DSE was higher in significant CAD compared to insignificant CAD (80% vs. 74%; p = 0.03). Conclusions: Compromised LV longitudinal systolic function, lower delta E wave, prolonged t-IVT, and increased WMSI were the most powerful independent predictors of the presence and significance of CAD. These finding strengthen the role of comprehensive DSE analysis in diagnosing ischemic disturbances secondary to significant CAD.

Diagnostic Accuracy of Dobutamine Stress Echocardiography for Detection of Cardiac Allograft Vasculopathy in Orthotopic Heart Transplant Patients.

ObjectiveCardiac allograft vasculopathy is one of the leading causes of late graft failure and subsequent death in orthotopic heart transplant. Although invasive coronary angiography is the gold standard modality for detection of cardiac allograft vasculopathy, dobutamine stress echocardiography has been recently frequently used as an alternative. Our aim was to evaluate the diagnostic performance of dobutamine stress echocardiography for detection of cardiac allograft vasculopathy in transplant patients.MethodsA retrospective analysis was conducted using a total of 150 dobutamine stress echocardiographic exams that were performed on 99 patients in our institution, with paired coronary angiogram and no acute rejection, within a median of 538 [interquartile range 371–816] days. Sensitivity and specificity of dobutamine echocardiography to detect allograft vasculopathy was evaluated. Allograft vasculopathy was defined as Grade 1 or higher based on ISHLT criteria. A positive dobutamine stress echo result was defined by new or worsening wall motion abnormality.ResultsMedian age of the population at transplant was 34 [interquartile range 22–46] years; 76 (77%) patients were male. Allograft vasculopathy was present in 31 (20.6%) out of 150 coronary angiograms. Only 7 (4.6%) of that number were positive on dobutamine stress echocardiography. Sensitivity and specificity for allograft vasculopathy detection was 3% and 94%, respectively. Out of 7 false positive dobutamine stress echocardiograms, two were in patients with myocardial bridging. Two patients with mild acute rejection had both negative dobutamine stress echo.ConclusionsOverall, positivity of dobutamine stress echocardiography in patients after heart transplant is low. It has high specificity, but very low sensitivity for detection of cardiac allograft vasculopathy. Dobutamine stress echocardiography should only be cautiously used as an alternative to coronary angiography.

Implications of Alterations in Pre-test Probability in the 2019 Update of ESC Guidelines for Chronic Coronary Syndromes on Diagnostic Accuracy of Pharmacological Stress-Echocardiography: A Retrospective Cohort Study.

BACKGROUNDWith the 2019 update of European Society of Cardiology (ESC) guidelines for chronic coronary syndromes, the pre-test probabilities (PTPs) based on age, sex, and symptoms have undergone major revisions. We aimed to determine implications of these alterations on diagnostic accuracy of dobutamine stress echocardiography (DSE).METHODSWe retrospectively included consecutive patients undergoing pharmacological stress-echocardiography for evaluation of suspected obstructive coronary artery disease. DSE was performed as non-invasive imaging test and was indicated by individual treating physician's decision. Sensitivity, specificity, positive and negative predictive value as well as accuracy were assessed for detection of obstructive coronary artery disease, defined as revascularization therapy following DSE.RESULTSWe included 206 patients (mean age 63.2 ± 12.4 years, 59.7% male). 51% of the cohort had a PTP of < 15% according to both scores. 9.2% of patients with PTP < 15% according to the original Diamond and Forrester score had a PTP > 15% according to 2019 ESC guidelines, predominantly due to the accountancy of dyspnea. In contrast, 13.6% of patient had a PTP ≥ 15% according to the original Diamond and Forrester score, while PTP was assessed below this threshold by updated guidelines. The differences in patient selection according to updated guidelines did not alter the diagnostic accuracy of DSE (68% for both).CONCLUSIONSChanges in assessment of PTP according to updated ESC guidelines from 2019 led to a relevant reclassification of patients with suspected coronary artery disease, ultimately changing the group of patients appropriate for DSE for evaluation of myocardial ischemia. Comparing the diagnostic performance in appropriate PTP groups, however, led to similar results.

Accuracy of Dobutamine Stress Echocardiography as A Predictor for Major Adverse Cardiovascular Events in Patients with Reduced Exercise Capacity Undergoing Major Non-Cardiac Surgery

Accuracy of Dobutamine Stress Echocardiography as A Predictor for Major Adverse Cardiovascular Events in Patients with Reduced Exercise Capacity Undergoing Major Non-Cardiac Surgery

Diagnostic accuracy of dobutamine stress echocardiography in the detection of cardiac allograft vasculopathy in heart transplant recipients: A systematic review and meta-analysis study.

Dobutamine stress echocardiography (DSE) is a well-established imaging modality used to screen patients with mild-to-moderate risk for coronary artery disease. In heart transplantation recipients, cardiac allograft vasculopathy (CAV) is a common and lethal complication. The use of DSE to detect CAV showed promising results initially, but later studies showed limitation in its use to detect CAV. It is unclear if this cohort of patients derives benefit from DSE. We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Scopus from inception through March 2018 for studies examining the accuracy of DSE in correlation to coronary angiography (CA) or intravascular ultrasound (IVUS) to detect CAV. Original studies comparing the ability of DSE to detect CAV in comparison with CA or IVUS were included. Relevant data were extracted and hierarchical summary receiver operating characteristic analysis was conducted to test the overall diagnostic accuracy of DSE for patients with CAV. Eleven studies (749 participants) met the inclusion criteria. The sensitivity of DSE varied from 1.7% to 93.8%, and specificity, from 54.8% to 98.8%. Pooled sensitivity was 60.2% (95% confidence interval (CI), 33.0%-82.3%) and specificity 85.7% (95% CI, 73.8%-92.7%). DSE had an overall diagnostic odds ratio (OR) of 9.1 (95% CI, 4.6-17.8), positive likelihood ratio (LR+) of 4.1 (95% CI, 2.8-6.1), negative likelihood ratio (LR-) of 0.47 (95% CI: 0.23-0.73), and area under curve (AUC) of 0.73 (95% CI, 0.72-0.75). Heterogeneity among studies was not statistically significant (τ2 =0.32, Cochran's Q=9.5, P=0.483). Dobutamine stress echocardiography has a limited sensitivity to detect early CAV but its specificity is much higher. There remains a need for an alternative noninvasive modality which will have both high sensitivity and high specificity for detecting CAV.

Predictive Accuracy of Dobutamine Stress Echocardiography in Detection of Presence and Extent of Coronary Artery Disease

Introduction: Exercise tolerance test (ETT) is an established screening test for coronary artery disease (CAD), but not feasible in 30−40% of patients. Dobutamine stress echocardiography (DSE) is an excellent alternative. Traditionally, inducible worsening of wall motion by 1 grade from baseline provides an index of CAD; worsening by 2 grade or more theoretically represents a more severe perfusion abnormality. The present study represents the inaugural experience of DSE at the National Institute of Cardiovascular Disease, Dhaka.&#x0D; Objective: To assess the predictive accuracy of DSE results with the presence and extent of CAD in subjects with suspected stable angina pectoris.&#x0D; Materials and Methods: In this prospective observational study, 35 subjects with intermediate to high probability of CAD were subjected to DSE followed by coronary angiography (CAG) within one month. Comparison of DSE results and predicted coronary artery involvement with angiographic findings were done. Overall sensitivity, specificity, accuracy as well as accuracy by arterial territory involvement were calculated.&#x0D; Results: DSE identified 82 abnormal segments, 66 with 1 grade change in 23 subjects (Group A) and 16 with 2 grade change in 8 subjects (Group B). CAG detected 54 significant lesions, 23 (42.59%) in left circumflex (LCX), 18 (33.33%) in left anterior descending (LAD), 11 (20.37%) in right coronary (RCA) and 2 (3.7%) in left coronary (LCA) artery. DSE had a sensitivity of 93.1% and a specificity of 66.7%. The accuracy was 88.57% overall, 94.29% for LAD and 91.43% for both LCX and RCA territories. Group B subjects had significantly higher number of coronary stenosis per patient (2.63 versus 1.38, p&lt;0.001), triple vessel (62.5% versus 8.6%, p=0.003) and lower single vessel CAD (0% versus 47.8%, p=0.005).&#x0D; Conclusion: This study shows that DSE is a reliable test for prediction of the presence and extent of CAD.&#x0D; J Enam Med Col 2019; 9(1): 16-24

Estimating the Accuracy of Dobutamine Stress Echocardiography and Single-Photon Emission Computed Tomography among Patients Undergoing Noncardiac Surgery.

When cardiac stress testing is ordered prior to noncardiac surgery, the optimal test modality is unknown. Therefore, we conducted this study to compare the diagnostic accuracy of dobutamine stress echocardiography (DSE) and single-photon emission computed tomography (SPECT) in a representative sample of patients undergoing noncardiac surgery without an existing diagnosis of coronary artery disease (CAD). The predicted accuracy of DSE was greater than that of SPECT in around 60.5% of cases above the current guideline-recommended risk threshold. In this population, DSE is likely to be more accurate than SPECT in the diagnosis of obstructive CAD. To the extent that making a diagnosis of obstructive CAD changes the decision to pursue noncardiac surgery, DSE likely represents a more efficient testing modality. However, in the range of pretest probabilities among this population, positive results from either test are more likely to represent false positives than true positives.

Safety and Diagnostic Accuracy of Dobutamine Stress Echocardiography

Exercise and pharmacologic stress echocardiography has been used routinely in clinical practice for the past twenty to thirty years. Dobutamine stress echocardiography (DSE) is well established as a safe, feasible, and accurate modality for detection of myocardial ischemia and prognostication in patients with known or suspected coronary artery disease, particularly when they have limited exercise capacity. Serious side effects during or shortly after DSE are uncommon, with ventricular fibrillation or myocardial infarction occurring in approximately 1 of 2,000 studies. No deaths have been reported. On the basis of a total number of 2,246 patients, reported in 28 studies, the sensitivity, specificity and accuracy of the test for the detection of coronary artery disease (CAD) were 80%, 84% and 81%, respectively. Mean sensitivities for one, two and three-vessel disease were 74%, 86% and 92%, respectively. The sensitivity of detection of disease in the let circumflex coronary artery (55%) was lower, both compared with that for left anterior descending (72%) and right coronary artery disease (76%). The sensitivity of predicting multivessel disease by multiregional echocardiographic abnormalities varied widely, from 8% to 71%. In direct comparisons, DSE was superior to exercise electrocardiography and dipyridamole echocardiography and comparable to exercise echocardiography and radionuclide imaging. DSE is useful, feasible and safe exercise independent stress modality for assessing the presence, localization and extent of CAD.

TCTAP A-161 Will Lower Limb Pneumatic Compression During Dobutamine Stress Echocardiography Increase Its Diagnostic Accuracy?

Pneumatic compression of the lower part of the body increases left ventricular afterload. We compared the diagnostic accuracy of dobutamine stress echocardiography (DSE) with pneumatic compression of the lower extremities, versus standard DSE, for detection of significant coronary artery disease (

Dobutamine stress echo has marginal utility and is context-dependent for assessing myocardial ischemia

A clinical appraisal and clinical application of Marcovitz PA, Armstrong WF. Accuracy of dobutamine stress echocardiography in detecting coronary artery disease. Am J Cardiol. 1992;69:1269-1273

0026: Uselessness of high-sensitivity cardiac troponins to improve diagnostic accuracy of dobutamine stress echocardiography in high-risk diabetic patients

Dobutamine stress echocardiography (DSE) is a well-established noninvasive stress modality for the detection and evaluation of coronary artery disease in diabetic patients. High-sensitivity cardiac troponin T recently emerged as a highly sensitive dosage for the detection of ischemia. The aim of the study was to examine whether high-sensitivity cardiac troponin T may improve the diagnostic accuracy of silent ischemia by DSE in high-risk diabetic patients. 21 patients with long-standing (>10 years) and/or complicated type II DM but no established CAD were included. In addition to DSE, venous blood samples for measurement of hs-cTnT and were collected prior to DSE, 6H and 24 hours after the test. Troponins were deemed positive if >1.5 upper limit for normality. Patients with positive troponins underwent coronary angiography or CT scan regardless of the result of DSE. Among the 21 patients, 7 had positive troponins measured 6 hours after stress, (mean peak troponin=44.5). DSE were negative in all of them. Mean age was 64 years significantly higher than patients with negative troponins. No differences were noted between the groups in terms of epidemiological, clinical or echocardiographic characteristics. Patients with positive cardiac troponins were evaluated for the presence of coronary lesions but none of them had significant disease. After a 18 month mean follow-up, no adverse cardiac events were noted in either groups. In high risk diabetic patients, the measurement of hs-cTnT during DSE does not improve the sensitivity at least in those with negative DSE tests

PT399 Diagnostic Accuracy of Dobutamine Stress Echocardiography in Korean Women with Chest Pain: Chest Pain in Korean Women’s Registry

PT399 Diagnostic Accuracy of Dobutamine Stress Echocardiography in Korean Women with Chest Pain: Chest Pain in Korean Women’s Registry

Predictive Value of Dobutamine Stress Echocardiography for Coronary Artery Disease Detection in Liver Transplant Candidates

Patients with obstructive coronary artery disease (CAD) undergoing orthotopic liver transplantation (OLT) are at increased risk of poor outcomes. The accuracy of dobutamine stress echocardiography (DSE) to detect obstructive CAD is not well established in this population. We retrospectively identified patients with end-stage liver disease who underwent both DSE and coronary angiography as part of risk stratification prior to OLT. One hundred and five patients had both DSE and angiography, of whom 14 had known CAD and 27 failed to reach target heart rate during DSE. Among the remaining 64 patients (45 men; average age 61 +/- 8 years) DSE had a low sensitivity (13%), high specificity (85%), low positive predictive value (PPV) (22%) and intermediate negative predictive value (NPV) (75%) for obstructive CAD. DSE as a screening test for obstructive CAD in OLT candidates has a poor sensitivity. The frequent chronotropic incompetence and low sensitivity in patients who achieve target heart rate, even in those with multiple cardiovascular disease risk factors, suggest that alternative or additional methods of risk stratification are necessary.

A Randomized Cross-Over Study for Evaluation of the Effect of Image Optimization With Contrast on the Diagnostic Accuracy of Dobutamine Echocardiography in Coronary Artery Disease: The OPTIMIZE Trial

The purpose of this study was to evaluate whether the addition of a contrast agent to dobutamine stress echocardiography (DSE) improves its diagnostic accuracy for coronary artery disease (CAD) and to determine the effect of image quality on the diagnostic impact of contrast agent use in this setting. Contrast agents can improve endocardial border definition. To date, however, there are no randomized trials that have evaluated the impact of contrast agent use on the accuracy of DSE. Patients referred for stress testing with dobutamine echocardiography underwent 2 DSE studies: 1 with and 1 without a contrast agent, at least 4 h apart in a randomized order and within a 24-h period. A total of 101 patients underwent both DSE studies. Similar hemodynamics were achieved during the 2 stress testing sessions. The use of a contrast agent improved the percentage of segments adequately visualized at baseline (from 72 +/- 24% to 95 +/- 8%) and more so at peak stress (67 +/- 28% to 96 +/- 7%); both p < 0.001. Interpretation of wall motion with high confidence also increased with contrast agent use from 36% to 74% (p < 0.001). Segment visualization with the use of a contrast agent improved in all views, but was more pronounced in the apical views. In unenhanced DSE, 36% of studies were normal, 51% had ischemia, and 8% were uninterpretable-all of which became interpretable with the use of a contrast agent. When compared with angiography (n = 92; 55 patients with CAD), accurate detection of ischemia was higher with contrast-enhanced studies versus nonenhanced studies (p = 0.02). As endocardial visualization and confidence of interpretation decreased in unenhanced studies, a greater impact of the use of a contrast agent on DSE accuracy was observed (p < 0.01). During dobutamine stress echocardiography, contrast agent administration improves endocardial visualization at rest and more so during stress, leading to a higher confidence of interpretation and greater accuracy in evaluating CAD. The lesser the endocardial border visualization, the higher the impact of contrast echocardiography on accuracy.

Value and limitations of dobutamine stress echocardiography in women with suspected coronary artery disease

The accuracy of exercise electrocardiography (ECG) for detecting coronary artery disease (CAD) in women is limited. Dobutamine stress echocardiography (DSE) is an alternative. Limited and conflicting data exist on the utility of DSE. This prospective study determines value and limitations of DSE compared with exercise ECG in women with suspected CAD. A total of 114 consecutive women without previous myocardial infarction underwent standard exercise ECG and DSE prior to coronary angiography performed within 5±2 days. Pretest probability of CAD was calculated from clinical parameters and significant CAD was defined as ≥50% coronary artery luminal narrowing. Prevalence of CAD was 39.5% with multivessel disease in 49%. Most patients had a low or intermediate pretest probability of CAD (75%). Exercise ECG recordings were diagnostic in 71% and DSE in 90% of women. Overall sensitivity, specificity and accuracy for DSE were superior to exercise ECG (80%, 81%, and 80%, respectively, versus 65%, 55%, and 59%, respectively; p<0.05). Accuracy of DSE was increased in multivessel disease (85%), good echocardiographic image quality (86%) compared to single vessel disease (73%) and moderate image quality (69%). Accuracy of DSE demonstrated little differences in subgroups of pretest probability (78–85%), whereas accuracy of exercise ECG ranged from 44% to 71%. DSE is superior to exercise ECG in the evaluation of suspected CAD in women. Accuracy of ST-segment analysis in exercise ECG remains questionable for the investigation of myocardial ischemia in women and may be supplemented or substituted by DSE.

Abstract 2086: Usefulness of Pneumatic Lower Extremity Compression During Dobutamine Stress Echocardiography

Background Afterload is expected to increase with pneumatic compression of the lower extremities. Therefore, left ventricular (LV) wall stress which is the most important factor determining myocardial oxygen demand will also increase, leading to an increase in sensitivity of dobutamine stress echocardiography (DSE) or shortened time to positive response.The purpose of this study was to evaluate the effect of pneumatic compression of lower extremities on the diagnostic accuracy of DSE. Methods In 40 patients who underwent DSE and were anticipating coronary angiography, DSE was repeated with the pneumatic compression (100mmHg) of lower extremities (DSEcomp) prior to coronary angiography. Sensitivity and specificity of DSE and DSEcomp were determined based on the coronary angiographic finding. Results All patients tolerated pneumatic compression of the lower extremities during the tests. LV end-systolic volume (p=0.042) and end-systolic wall stress (p=0.036) were significantly greater in the DSEcomp than DSE. In 3 patients with false negative results in DSE, DSEcomp showed positive responses, demonstrating a significant increase in sensitivity from 75% to 94% (p=0.045). Only 1 patient with true negative result in DSE was interpreted as showing positive response in DSEcomp, resulting in a decrease in specificity from 88% to 83% (p=NS). In 11 of 13 patients with true positive results both in DSE and DSEcomp, positive responses were seen at least 1 stage earlier in DSEcomp compared to DSE. Conclusions Pneumatic compression of lower extremities increases the sensitivity of DSE and shortens the time to positive response.

Ischaemia imaging in type 2 diabetic kidney transplant candidates is coronary angiography essential?

Coronary artery disease (CAD) remains the leading cause of death in type 2 diabetes mellitus (DM) patients undergoing renal transplantation. There is a high prevalence of silent CAD in these patients. Controversy exists regarding the role of dobutamine stress echocardiography (DSE) in detection of CAD. Our purpose was to compare DSE with coronary angiography (CA) for the detection of CAD in type 2 diabetic patients undergoing evaluation for renal transplantation. Forty (36 male, four female) type 2 diabetic patients with end-stage renal disease (ESRD) were subjected to DSE followed by CA as a part of their pre-renal transplant evaluation. The ability of DSE to predict 70% stenosis in one or more coronary arteries as determined by CA was evaluated. Mean age of the patients was 49.2 +/- 5 years (range 39-60 years). DSE was positive in 10 (25%) patients, while 19 patients (48%) had a more than 70% lesion in at least one epicardial vessel on CA (six patients had single vessel, three had double vessel and 10 had triple vessel disease). The sensitivity and specificity in identifying CAD was 47.3 and 95.2%, respectively, while positive predictive value and negative predictive value was 90% and 66%. Accuracy of DSE was 72.5%. All four patients with diffuse diabetic coronary artery disease had negative DSE. DSE is a poor predictor of coronary artery disease in type 2 DM patients being evaluated for renal transplantation. CA should be included in evaluation of type 2 diabetic patients who are renal transplant candidates.

205 Enhanced accuracy of dobutamine stress echocardiography with the acute administration of intravenous atenolol during the recovery phase

205 Enhanced accuracy of dobutamine stress echocardiography with the acute administration of intravenous atenolol during the recovery phase

Usefulness of Ultrasound Contrast Agent to Improve Image Quality During Real-Time Three-Dimensional Stress Echocardiography

Dobutamine stress echocardiography is an accepted tool for the diagnosis of coronary artery disease. Some investigators have claimed that 3-dimensional imaging improves the diagnostic accuracy of dobutamine stress echocardiography. The purpose of the present investigation was to examine the role of contrast echocardiography in the improvement of segmental quality and interobserver agreement during stress real-time 3-dimensional echocardiography (RT3DE). The study comprised 36 consecutive patients with stable chest pain referred for routine stress testing. Three-dimensional images were acquired with an RT3DE system with an X4 matrix-array transducer. All available reconstructed 2-dimensional segments were graded as optimal, good, moderate, or poor. Wall motion was scored as normal, mild hypokinesia, severe hypokinesia, akinesia, or dyskinesia. At peak stress, 466 of the 612 segments (76%) could be analyzed during conventional RT3DE. With contrast-enhanced RT3DE, the number of available segments increased to 553 (90%). The image quality index during conventional RT3DE was 2.2, whereas with contrast-enhanced RT3DE, it was 3.1. With conventional RT3DE, 2 independent observers agreed on the diagnosis of myocardial ischemia in 85 of 108 coronary territories (79%, kappa = 0.26). With contrast-enhanced RT3DE, agreement increased to 95 of 108 coronary territories (88%, kappa = 0.59). Study agreement on myocardial ischemia was present in 26 of 36 studies (72%, kappa = 0.43) with conventional RT3DE and in 32 of 36 studies (89%, kappa = 0.77) with contrast-enhanced RT3DE. In conclusion, during stress RT3DE, contrast-enhanced imaging significantly decreases the number of poorly visualized myocardial segments and improves interobserver agreement for the diagnosis of myocardial ischemia.